Roger Hamer
PFD Report
All Responded
Ref: 2017-0259
All 2 responses received
· Deadline: 2 Jan 2018
Coroner's Concerns (AI summary)
Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, particularly for cyclists, by raising the threshold for defect investigation and repair.
View full coroner's concerns
(1) When he inspected the carriageway in January 2016 and February 2016 the highway inspector did not photograph, measure and/or record any details as to the condition of the carriageway where the Pothole developed despite it having started to deteriorate, wear and crack by October 2015. This prevented the Highway Authority from effectively assessing the rate of deterioration of this part of the carriageway which may have helped to inform it as to the need for earlier repair. Also, the lack of images and/or measurements of the Pothole as at the date of the inspections restricted the Highway Authority’s ability to effectively supervise and monitor the highway inspector and it hindered the jury’s ability to make more detailed findings as to the circumstances of Mr Hamer’s death.
(2) The jury recorded its concern as to the lack of paint markings around the potholes which may have highlighted their presence to Mr Hamer thereby enabling him to avoid them.
(3) The Highway Authority does not have a procedure with a duty of candour for the effective investigation of, and learning lessons from, significant incidents comparable to those adopted by other public bodies (for example within the National Health Service).
(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016. With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired. Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed. If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired. Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists.
(2) The jury recorded its concern as to the lack of paint markings around the potholes which may have highlighted their presence to Mr Hamer thereby enabling him to avoid them.
(3) The Highway Authority does not have a procedure with a duty of candour for the effective investigation of, and learning lessons from, significant incidents comparable to those adopted by other public bodies (for example within the National Health Service).
(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016. With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired. Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed. If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired. Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists.
Responses
Action Planned
Bury Council, as Highway Authority, states that all Highway Inspectors are scheduled to undergo specific training and competency checks to ensure they understand how to undertake their role under the new Code of Practice. There will be regular evidence based reviews of the new Code of Practice and monitoring. (AI summary)
Bury Council, as Highway Authority, states that all Highway Inspectors are scheduled to undergo specific training and competency checks to ensure they understand how to undertake their role under the new Code of Practice. There will be regular evidence based reviews of the new Code of Practice and monitoring. (AI summary)
View full response
Dear Sirs Inquest touching the death of Roger Hamer (deceased) Regulation 28 Report to Prevent Future Deaths was sent to Council dated 215t August 2017 following the investigation into the death of Roger Hamer which concluded at the end of the inquest on 11t August 2017 . The response set out below seeks to address the Coroner's concerns raised in Box 5 as follows:
1) Bury Council; as Highway Authority, ensured that their procedures and systems of inspection were in accordance with best practice guidance as set out within the Well Maintained Highways A Code of Practice for Highway Maintenance Management 2009. Highway Inspectors during the course of safety inspections and when responding to specific complaints are trained and instructed to undertake an on- site risk based assessment of any safety danger which may give rise to a risk of injury: AII identified safety defects giving rise to a real source of danger to reasonable users of the highway would be recorded by the highway inspector on to handheld device which identifies the nature, location and type of defect to enable the repair team to easily identify the repair when an order is raised. For operational and safety issues not all safety defects identified in the carriageway would be measured as this in itself would raise risk management safety concerns for the highway inspector who may be faced with oncoming traffic. Highway inspectors using their experience of identifying safety defects would use their on-site judgment in assessing any safety defect and order time response repair accordingly: Electronic or fax service of Legal documents is not accepted Town Hall; Knowsley Street, Bury; BL9 OSW WWW bury.gov.uk B u r Y P r e $ t W c h R a d € ] ! f f e R a m $ b 0 t t 0 m To tt! n 9 t 0 n W h te f e | d Bury
Due to the technology requirements which would be required and the storage facilities for photographs of defects have not previously been taken: There is no specific guidance with the Code of Practice that this was deemed to be good practice or a requirement. The in their narrative recorded that accurate measurements of each defect and use of spray paint and pictorial evidence are only used for insurance claims and not all defects identified: That is the case in insurance claims in order to secure and preserve available evidence which are requirements for the purposes of establishing the nature of the defect and where measurements of defects are helpful in order to assess whether particular defect would be deemed to be a real source of danger as & matter of Iaw: All safety defects identified in the footway are measured if borderline with industry standard intervention levels of safety defects or defects may be visibly obvious to represent a danger without the need to measure defect during safety inspections: Appropriate repair orders are raised to allow the repair teams to respond to remedy and repair safety defects within timescales which are based on and dependent on the level of risk posed by a particular safety defect, given its location and use etc. Each Highway inspector is assigned an area in which operate and out safety inspections to scheduled inspections or in response to specific enquiries from members of the public. New Road, Ramsbottom, was subject to regular monthly safety inspections which was in accordance with the recommendation of the Code of Practice. Given the regular frequency of safety inspections being undertaken on this highway, the Highway Inspector was essentially monitoring and assessing the condition of the highway in order to ensure that there were no safety defects which gave rise to real source of danger: It is not accepted that the lack of images or measurements of the pothole restricted the Highway Authority's ability to effectively supervise and monitor the highway inspector or did not allow it to comply with its statutory duty under the Highway Act 1980 to ensure that they had taken such care as in all the circumstances was reasonably required to secure that part of the highway was not dangerous for traffic. Due to investment in the highway maintenance procedures and IT systems, highway inspectors now routinely take photographs of defects giving rise to real source of danger: Repair crews also take photographs prior to and post repair.
2) The Highway Authority does not paint markings around potholes especially in the carriageway: As identified above this is for reasons of safety of the highway inspector who would otherwise place himself in a position of danger caused by traffic. Paint markings are not used to highlight defects to users of the highway: If were historically used then this would have been to allow a pothole raised for repair to be identified by the repair team: The need to mark defects is no longer data, Jury they camy Bury they
necessary given two factors, namely the use of handheld GPS devices which CO-ordinates the exact location of the defect requiring repair and the repair response time when safety defects are identified using the risk based matrix for repair: Given the speed at which vehicular traffic uses New Road, Ramsbottom; the Highway Authority contend that markings alone would not have been sufficient to highlight the presence of the pothole to Mr Hamer: If a safety defect is identified to represent an imminent danger to users then Highway Inspector can order emergency repairs requiring repairs within 2 hours or 24 hours dependent on the nature of the risk:
3) GMP investigates highway incidents and reports these to Council by the STATS 19 process: incidents linked to road defects (either condition or layout) are acted upon as soon as possible. The Council have acknowledged the need for a formal procedure to be implemented for follow up investigation following such notifications of incidents from the GMP , It is proposed to implement procedure by March
2018. The DFT commissioned a report to review the current Code of Practice. The UK Roads Liason Group published "Well-Managed Highway Infrastructure A Code of Practice" in October
2016. In addition, the Institute of Highway Engineers provided guidance on risk and Iiability within the highways sector in a publication 'Well Managed Highways Liability Risk" in March 2017 . The emphasis and recommendations of the new guidance Code is for Highway Authorities to implement local levels of service through risk based assessment There is change from reliance on specific guidance and recommendations to risk based approach determined by each Highway Authority which involves appropriate analysis, development and requires approval through the executive process: Highway Authorities are also required to collaborate with neighbouring authorities in determining levels of service across boundaries. The Code is not statutory but guidance only, based on Highway Authorities own legal interpretation, risks, needs and priorities. The Risk based approach of the code" will consider all road users Including the varying types of users including cyclists There is a recommendation that all defects observed that provide a risk t0 users should be recorded and the level of response shall be based on the Highway Inspector applying a risk based matrix to assess the likely impact of a safety defect and the probabilityllikelihood of interaction with highway users_ This is an on-site assessment made by the Highway Inspector based on various factors including location, the classification of the highway, the level of traffic that uses or likely to use highway where a safety defect is identified. The emphasis is on local discretion: Bury Bury Any "new
Council in collaboration with the other 9 Greater Manchester Highway Authorities; are seeking to agree an "Overarching Framework of Agreed Principles" which would provide consistency of approach across the boundaries on the following matters: frequency and classification of highways, the risk based approach to safety inspections, the risk based approach to repair timescales; the investigatory levels which would trigger the Highway inspector to apply the risk based matrix for assessing the risk: Given the basis of the risk based approach for safety inspections, Highway Inspectors would have on-site discretion to identify safety defects which do not meet the investigatory level, applying the risk based criteria and order repairs where necessary taking into account various factors including pedestrian volume, traffic sensitive routes, accident data, character and traffic use and location and positioning of the safety defect: Although some general guidance can be given on the likely risk associated with particular defects, on-site judgment will need to take into account of particular circumstances_ AII Highway Inspectors are scheduled to undergo specific training and competency checks to ensure that understand how to undertake their role under the new Code of Practice. The Highway Authority aim is to ensure consistency of approach in application of both the current and the new Code of Practice. The new risk based approach and specific training of inspectors on their role in accordance with the WMHI Code of Practice should allow the Highway Authority to apply a consistent risk based approach where the reasons for taking specific decisions will be evidenced. There will be regular evidence based reviews of the new Code of Practice and monitoring: Safety inspections are designed to identify all defects likely to create danger or serlous inconvenience to users of the highway network; The risk of danger Is assessed on site and the defect identified with an appropriate priority response Long term planned maintenance schemes in conjunction with safety inspections are undertaken by means of condition surveys, which are primarily intended to identify deficiencies which if untreated, are likely to adversely affect long term performance , serviceability and safety: It is recognised that the loss of life is a tragedy in any circumstances and the Council are focused on ensuring that there are lessons leamt from such incidents and that their highway network is as safe as reasonably practicable for rad users by managing the presence of any safety defects on the highway:
1) Bury Council; as Highway Authority, ensured that their procedures and systems of inspection were in accordance with best practice guidance as set out within the Well Maintained Highways A Code of Practice for Highway Maintenance Management 2009. Highway Inspectors during the course of safety inspections and when responding to specific complaints are trained and instructed to undertake an on- site risk based assessment of any safety danger which may give rise to a risk of injury: AII identified safety defects giving rise to a real source of danger to reasonable users of the highway would be recorded by the highway inspector on to handheld device which identifies the nature, location and type of defect to enable the repair team to easily identify the repair when an order is raised. For operational and safety issues not all safety defects identified in the carriageway would be measured as this in itself would raise risk management safety concerns for the highway inspector who may be faced with oncoming traffic. Highway inspectors using their experience of identifying safety defects would use their on-site judgment in assessing any safety defect and order time response repair accordingly: Electronic or fax service of Legal documents is not accepted Town Hall; Knowsley Street, Bury; BL9 OSW WWW bury.gov.uk B u r Y P r e $ t W c h R a d € ] ! f f e R a m $ b 0 t t 0 m To tt! n 9 t 0 n W h te f e | d Bury
Due to the technology requirements which would be required and the storage facilities for photographs of defects have not previously been taken: There is no specific guidance with the Code of Practice that this was deemed to be good practice or a requirement. The in their narrative recorded that accurate measurements of each defect and use of spray paint and pictorial evidence are only used for insurance claims and not all defects identified: That is the case in insurance claims in order to secure and preserve available evidence which are requirements for the purposes of establishing the nature of the defect and where measurements of defects are helpful in order to assess whether particular defect would be deemed to be a real source of danger as & matter of Iaw: All safety defects identified in the footway are measured if borderline with industry standard intervention levels of safety defects or defects may be visibly obvious to represent a danger without the need to measure defect during safety inspections: Appropriate repair orders are raised to allow the repair teams to respond to remedy and repair safety defects within timescales which are based on and dependent on the level of risk posed by a particular safety defect, given its location and use etc. Each Highway inspector is assigned an area in which operate and out safety inspections to scheduled inspections or in response to specific enquiries from members of the public. New Road, Ramsbottom, was subject to regular monthly safety inspections which was in accordance with the recommendation of the Code of Practice. Given the regular frequency of safety inspections being undertaken on this highway, the Highway Inspector was essentially monitoring and assessing the condition of the highway in order to ensure that there were no safety defects which gave rise to real source of danger: It is not accepted that the lack of images or measurements of the pothole restricted the Highway Authority's ability to effectively supervise and monitor the highway inspector or did not allow it to comply with its statutory duty under the Highway Act 1980 to ensure that they had taken such care as in all the circumstances was reasonably required to secure that part of the highway was not dangerous for traffic. Due to investment in the highway maintenance procedures and IT systems, highway inspectors now routinely take photographs of defects giving rise to real source of danger: Repair crews also take photographs prior to and post repair.
2) The Highway Authority does not paint markings around potholes especially in the carriageway: As identified above this is for reasons of safety of the highway inspector who would otherwise place himself in a position of danger caused by traffic. Paint markings are not used to highlight defects to users of the highway: If were historically used then this would have been to allow a pothole raised for repair to be identified by the repair team: The need to mark defects is no longer data, Jury they camy Bury they
necessary given two factors, namely the use of handheld GPS devices which CO-ordinates the exact location of the defect requiring repair and the repair response time when safety defects are identified using the risk based matrix for repair: Given the speed at which vehicular traffic uses New Road, Ramsbottom; the Highway Authority contend that markings alone would not have been sufficient to highlight the presence of the pothole to Mr Hamer: If a safety defect is identified to represent an imminent danger to users then Highway Inspector can order emergency repairs requiring repairs within 2 hours or 24 hours dependent on the nature of the risk:
3) GMP investigates highway incidents and reports these to Council by the STATS 19 process: incidents linked to road defects (either condition or layout) are acted upon as soon as possible. The Council have acknowledged the need for a formal procedure to be implemented for follow up investigation following such notifications of incidents from the GMP , It is proposed to implement procedure by March
2018. The DFT commissioned a report to review the current Code of Practice. The UK Roads Liason Group published "Well-Managed Highway Infrastructure A Code of Practice" in October
2016. In addition, the Institute of Highway Engineers provided guidance on risk and Iiability within the highways sector in a publication 'Well Managed Highways Liability Risk" in March 2017 . The emphasis and recommendations of the new guidance Code is for Highway Authorities to implement local levels of service through risk based assessment There is change from reliance on specific guidance and recommendations to risk based approach determined by each Highway Authority which involves appropriate analysis, development and requires approval through the executive process: Highway Authorities are also required to collaborate with neighbouring authorities in determining levels of service across boundaries. The Code is not statutory but guidance only, based on Highway Authorities own legal interpretation, risks, needs and priorities. The Risk based approach of the code" will consider all road users Including the varying types of users including cyclists There is a recommendation that all defects observed that provide a risk t0 users should be recorded and the level of response shall be based on the Highway Inspector applying a risk based matrix to assess the likely impact of a safety defect and the probabilityllikelihood of interaction with highway users_ This is an on-site assessment made by the Highway Inspector based on various factors including location, the classification of the highway, the level of traffic that uses or likely to use highway where a safety defect is identified. The emphasis is on local discretion: Bury Bury Any "new
Council in collaboration with the other 9 Greater Manchester Highway Authorities; are seeking to agree an "Overarching Framework of Agreed Principles" which would provide consistency of approach across the boundaries on the following matters: frequency and classification of highways, the risk based approach to safety inspections, the risk based approach to repair timescales; the investigatory levels which would trigger the Highway inspector to apply the risk based matrix for assessing the risk: Given the basis of the risk based approach for safety inspections, Highway Inspectors would have on-site discretion to identify safety defects which do not meet the investigatory level, applying the risk based criteria and order repairs where necessary taking into account various factors including pedestrian volume, traffic sensitive routes, accident data, character and traffic use and location and positioning of the safety defect: Although some general guidance can be given on the likely risk associated with particular defects, on-site judgment will need to take into account of particular circumstances_ AII Highway Inspectors are scheduled to undergo specific training and competency checks to ensure that understand how to undertake their role under the new Code of Practice. The Highway Authority aim is to ensure consistency of approach in application of both the current and the new Code of Practice. The new risk based approach and specific training of inspectors on their role in accordance with the WMHI Code of Practice should allow the Highway Authority to apply a consistent risk based approach where the reasons for taking specific decisions will be evidenced. There will be regular evidence based reviews of the new Code of Practice and monitoring: Safety inspections are designed to identify all defects likely to create danger or serlous inconvenience to users of the highway network; The risk of danger Is assessed on site and the defect identified with an appropriate priority response Long term planned maintenance schemes in conjunction with safety inspections are undertaken by means of condition surveys, which are primarily intended to identify deficiencies which if untreated, are likely to adversely affect long term performance , serviceability and safety: It is recognised that the loss of life is a tragedy in any circumstances and the Council are focused on ensuring that there are lessons leamt from such incidents and that their highway network is as safe as reasonably practicable for rad users by managing the presence of any safety defects on the highway:
Noted
The Department for Transport acknowledges the concerns but notes that local highway authorities have a duty to maintain the highways network in their area and that Central Government has no powers to override local decisions in these matters. They endorse a code of practice, issued by the UK Roads Liaison Group, providing guidance to highway authorities on how to maintain and manage their highways. (AI summary)
The Department for Transport acknowledges the concerns but notes that local highway authorities have a duty to maintain the highways network in their area and that Central Government has no powers to override local decisions in these matters. They endorse a code of practice, issued by the UK Roads Liaison Group, providing guidance to highway authorities on how to maintain and manage their highways. (AI summary)
View full response
Dear Mr Sigee, 20 September2017 Thank you for providing me a copy of your report into the death of Mr Roger Hamer. I was very saddened to hear of the circumstances leading to Mr Hamer’s death. The Department for Transport considers the safety of all road users, including cyclists, a priority. The Government is providing just under £6 billion from 2015 to 2021 to allow local highway authorities in England, outside of London, to improve the condition of local roads across they are responsible for. In addition, we have topped this funding up with an extra £250 million specifically to tackle the blight of potholes. However, as you will be aware, local highway authorities, in this case Bury Council, have a duty under Section 41 of the Highways Act 1980 to maintain the highways network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of its network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. Central Government has no powers to override local decisions in these matters. That said, the Department endorses a code of practice, issued by the UK Roads Liaison Group of which we are a member. This code of practice provides guidance to highway authorities on how to maintain and manage their highways: http://www.ukroadsliaisonqroup.orcj/en/utilities/document summary.cfm?docid4F93BAl 0-D3BO-4222-827A8C48401 B26AC
In accordance with Section 41 of the Highways Act 1980 and the code of practice, it is for local authorities to decide and determine the dimension of a pothole as a basis for their decision-making. This could include adopting a risk-based approach where a highway inspector makes a judgement. Most authorities adopt an approach that combines consideration of both the dimensions and the risk. I hope this letter has been helpful. Rt Hon Chris Grayling MP SECRETARY OF STATE FOR TRANSPORT
In accordance with Section 41 of the Highways Act 1980 and the code of practice, it is for local authorities to decide and determine the dimension of a pothole as a basis for their decision-making. This could include adopting a risk-based approach where a highway inspector makes a judgement. Most authorities adopt an approach that combines consideration of both the dimensions and the risk. I hope this letter has been helpful. Rt Hon Chris Grayling MP SECRETARY OF STATE FOR TRANSPORT
Sent To
- Bury Metropolitan Borough Council
- Department for Transport
Response Status
Linked responses
2 of 2
56-Day Deadline
2 Jan 2018
All responses received
About PFD responses
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 2nd April 2016 the senior coroner for the coroner area of Greater Manchester North commenced an investigation into the death of Mr Roger Hamer, aged 83 years. The investigation concluded at the end of the inquest on 11th August 2017.
The conclusion of the inquest was that the medical cause of Mr Hamer’s death was (1A) traumatic brain injury and (2) multiple fractures.
The jury gave a narrative verdict in which they found that Mr Hamer had probably been caused to fall from his bicycle and to suffer the injuries from which he died by a pothole in the carriageway (“the Pothole”).
The conclusion of the inquest was that the medical cause of Mr Hamer’s death was (1A) traumatic brain injury and (2) multiple fractures.
The jury gave a narrative verdict in which they found that Mr Hamer had probably been caused to fall from his bicycle and to suffer the injuries from which he died by a pothole in the carriageway (“the Pothole”).
Circumstances of the Death
On 5th March 2016 Mr Hamer fell from his bicycle on Bury New Road, Ramsbottom, suffering a traumatic brain injury and multiple fractures. He was conveyed to hospital where despite maximal treatment he died from these injuries on 2nd April 2016.
Bury MBC is the highway authority responsible for the maintenance of this part of the public highway (“the Highway Authority”).
A subsequent police investigation identified 3 potholes in the carriageway near to where Mr Hamer fell. The Pothole was the largest of these defects and on 5th March 2016 the police measured it as being 0.6m wide (at its widest point), 1.5m long and generally in excess of 50mm deep.
Google Streetview images confirmed that the location where the Pothole developed was already showing signs of deterioration, wear and cracking in October 2015. The jury accepted the evidence given by a senior police collision investigator and the Highway Authority’s group engineer for highway maintenance that this part of the carriageway would have continued to deteriorate until it was repaired. Bury New Road was subject to a monthly inspection regime by the Highway Authority, and it was inspected on 19th January 2016 and 23rd February 2016. The 23rd February 2016 inspection followed a complaint by a local resident regarding the Pothole which was causing her concern. The highway inspector did not record any details in either of these inspections as to the condition of the carriageway in the location where the Pothole was found and, contrary to the October 2015 images, he asserted that this part of the carriageway was still intact at the date of his last inspection.
On 23rd February 2016 the highway inspector did identify another pothole near to this part of the carriageway and he issued an instruction that it be repaired within 28 days. These repairs would have extended to repair the Pothole. These repairs were not completed until after Mr Hamer had fallen from his bicycle.
Bury MBC is the highway authority responsible for the maintenance of this part of the public highway (“the Highway Authority”).
A subsequent police investigation identified 3 potholes in the carriageway near to where Mr Hamer fell. The Pothole was the largest of these defects and on 5th March 2016 the police measured it as being 0.6m wide (at its widest point), 1.5m long and generally in excess of 50mm deep.
Google Streetview images confirmed that the location where the Pothole developed was already showing signs of deterioration, wear and cracking in October 2015. The jury accepted the evidence given by a senior police collision investigator and the Highway Authority’s group engineer for highway maintenance that this part of the carriageway would have continued to deteriorate until it was repaired. Bury New Road was subject to a monthly inspection regime by the Highway Authority, and it was inspected on 19th January 2016 and 23rd February 2016. The 23rd February 2016 inspection followed a complaint by a local resident regarding the Pothole which was causing her concern. The highway inspector did not record any details in either of these inspections as to the condition of the carriageway in the location where the Pothole was found and, contrary to the October 2015 images, he asserted that this part of the carriageway was still intact at the date of his last inspection.
On 23rd February 2016 the highway inspector did identify another pothole near to this part of the carriageway and he issued an instruction that it be repaired within 28 days. These repairs would have extended to repair the Pothole. These repairs were not completed until after Mr Hamer had fallen from his bicycle.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.